Independent Medical Review/Complaint Forms

Submit an IMR / Complaint Form by Mail or Fax

Please select the desired form from the list below. Once completed, please sign and either mail or fax the form and copies of any supporting documents to:

Help Center
Department of Managed Health Care
980 9th Street, Suite 500
Sacramento, CA 95814

Fax: 916-255-5241

Authorized Assistant Form

If you want to give another person permission to help you with your Independent Medical Review (IMR) or Complaint, use the form below. You have the option to send the form either as an attachment with your online IMR/Complaint Form, or with your supporting documents by mail or fax.

We can not talk to another person about your case unless you sign this form:


Independent Medical Review / Complaint Forms

You must have Adobe Reader to print the forms below. You can download Adobe Reader for free to your computer. Click for directions.

English

Independent Medical Review (IMR) Application / Complaint Form

Español

Formulario de queja/solicitud de revisión médica independiente (IMR)

Arabic

طلب مراجعة طبية مستقلة/ نموذج الشكوى

Armenian

ԱՆԿԱԽ ԲԺՇԿԱԿԱՆ ՎԵՐԱՔՆՆՈՒԹԵԱՆ ԴԻՄՈՒՄՆԱԳԻՐ (IMR)/ԳԱՆԳԱՏԻ ՁԵՒԱԹՈՒՂԹ

Chinese

獨立醫療審查申請(IMR)/投訴表格

Farsi

فرم درخواست برای بازنگری پزشکی مستقل (IMR)/شکایت

Hmong

DAIM NTAWV TSO NPE THOV KOM ROV XYUAS KEV KHO MOB UAS NCAJ Nrab (IMR)/Daim Foos Tsis Txaus Siab

Khmer/Cambodian

ពាក្យស្នើសុំការពិនិត្យវេជ្ជសាស្រ្តឯករាជ្យ (IMR)/សំណុំបែបបទបណ្តឹង

Korean

독립 의료 검토 신청서(IMR)/불만양식

Lao

ໃບສະໝັກ(IMR)/ແບບຟອມຄຳຮ້ອງຂໍທົບທວນການເບິ່ງແຍງສຸຂະພາບແບບອິດສະລະ 

Russian

Заявка на проведение независимой медицинской проверки (IMR)/Форма жалобы

Tagalog 

PORMA NG REKLAMO/APLIKASYON SA MALAYANG PAGSUSURING MEDIKAL

Vietnamese

MẪU ĐƠN YÊU CẦU XEM XÉT Y TẾ ĐỘC LẬP (IMR)/KHIẾU NẠI

Japanese

独立医療審査 (IMR) 申し立て/苦情用紙

Punjabi

INDEPENDENT MEDICAL REVIEW (IMR) APPLICATION/COMPLAINT FORM

Thai 

INDEPENDENT MEDICAL REVIEW (IMR) APPLICATION/COMPLAINT FORM

Hindi

INDEPENDENT MEDICAL REVIEW (IMR) APPLICATION/COMPLAINT FORM

 Have additional questions? Take a look at our Frequently Asked Questions.

Need Help with Your Health Plan?

Call the DMHC Help Center

1-888-466-2219

or submit an Online Complaint

Need Help with Your Health Plan?

Call the DMHC Help Center

1-888-466-2219

or submit an Independent Medical Review/Complaint Form

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